Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model
Authors: Adam S. Wilk, Kelsey M. Drewry, Rebecca Zhang, Stephen O. Pastan, Rebecca Thorsness, Amal N. Trivedi, Rachel E. Patzer
Journal: JAMA Network Open (2022)

<h3>Importance</h3> In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC–assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics. <h3>Objective</h3> To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations. <h3>Design, Setting, and Participants</h3> This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022. <h3>Exposures</h3> Assignment to the ETC model. <h3>Main Outcomes and Measures</h3> Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics. <h3>Results</h3> Among 316 927 patients, with 6 178 855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132 462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average. <h3>Conclusions and Relevance</h3> In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes.